Over and beyond stereotypes

Health services and quality in Burkina Faso

A particularly advanced interpretation and management of the health issue despite difficulties and deficiencies.

by Alain Dominique Zoubga


As this article by Alain Dominque Zoubga explains, in a country like Burkina Faso the concern with the quality of health services is not a "luxury", but a necessity. Quality is a kind of fly-wheel and guideline for change and the rationalization of health policies, besides being a guarantee for the people. Zoubga describes the situation in his country as regards research, planning and actual experience.

Participants at the Quality Improvement and Recognition (QIR) Key Decisions Meeting. Arusha, Tanzania Source: JHU/CCP, Photoshare.

The Gross Domestic Product (GDP) per inhabitant of Burkina Faso was estimated at US$ 300 per year during the period 1993 - 1998. This places Burkina amongst the least developed countries (LDC) of the world.

In spite of differences in social organisation, the family remains the unit of reference on which all relations between community members are based. The extended family provides first support in case of illness or social or economic difficulties.

The 1996 poverty report (INSD, 1996) indicates that 44.5% of the population lives under the poverty line established in 1994, at 112 FCFA per adult per day, or 41,099 FCFA (US$ 82,2) per adult per year, of which 22,000 would be allocated to subsistence expenditure.

The economy is based mainly on the primary sector (agriculture, livestock), which - according to the 1996 population census - employs up to 91% of the working population and therefore is the largest provider of employment.

The secondary sector (industry) contributes 18% of GDP and is not strongly developed. It is dominated by manufacturing (textile, building and public works, agro-industry, chemical industry, etc.) and an underexploited mining sector.

The tertiary sector employs 4% of the labour force and contributes 40% of GDP. It includes traditional segments related to commerce and service provision.

Health situation

Award ceremony for "Gold Circle" champions at the Ouahigouya site. Burkina Faso Source: JHU/CCP, Photoshare.

The health situation in Burkina Faso is characterised by high mortality rates. Even as the general specific mortality rate and specific rates according to target groups or causes are decreasing, they remain high. The gross mortality rate decreased from 17‰ in 1985 to 16.4‰ in 1996. The female mortality rate passed from 17.5‰ in 1985 to 13.5‰ in 19961 . The infant mortality rate decreased from 134‰ in 1985 to 104‰ in 1998-1999.

The infant mortality rate is higher in rural areas, where it is 113‰ compared to 93.7‰ in urban zones (Poverty profile survey, 1995).

Maternal mortality rates remain extremely high with estimations of 485 maternal deaths for 100,000 births in 1996, whereas some international institutions estimate the rate to be as high as 930 for 100,000 births.

If we do not take into account HIV/AIDS incidence, life expectancy at birth increased from 32 years in 1960-61 to 52.2 years in 1996.

General morbility is high (15% in 1995)2 and is due to infectious and parasitical disease on the one hand, and to major endemics on the other hand.

In addition to these infectious and parasitical diseases, major endemics including tuberculosis, trypanosomiasis, schistosomiasis and leprosy remain public health problems.

In Burkina Faso, HIV/AIDS is one of the emerging diseases, progressing rapidly and expanding to all social segments of society.

In addition to the above-mentioned "emergency diseases", we need to mention problems related to water, sanitation and prevention services, which are problems linked to the organisation and functioning of facilities and to availability of resources. Thus, in our analysis of the health situation, we were able to identify several health problems in the country.


2. THE PROBLEM OF QUALITY IN BURKINA FASO

2.1. Priority health problems

2.1.1. General morbility and mortality are high

The morbidity of the Burkina population is high, particularly amongst children under 5 and elderly. Its causes lay mainly with the persistence of local endemic-epidemics and chronic diseases.

The high mortality is mainly due to high infant mortality, mortality of children up to 15 years and maternal mortality. Maternal deaths are primarily caused by infections, haemorrhage and dystocia.

Morbidity and mortality are also exacerbated by traffic accidents, trauma and violence.

Furthermore, existing programmes fighting disease are not very effective, and hygiene and sanitation measures insufficient.

2.1.2. HIV/AIDS prevalence is high

HIV seroprevalence rates are high in the general population of Burkina Faso, with the population between 15 and 40 years old being most affected. In spite of this elevated prevalence, there is under-reporting of cases. High prevalence is mainly due to considerable migration flows, persistence of key socio-cultural burdens and lack of effectiveness of prevention programmes. Consequences of the pandemic include the weakening of social networks, the disorganisation of health services and negative effects on the national economy.

2.1.3. Geographic and financial access of the population to health services is limited

Health workers at a market singing and carrying visual aids and a megaphone. Nigeria. Source: JHU/CCP, Photoshare.

The national infrastructure coverage is largely insufficient, in addition to an unequal distribution of health structures over the regions. In spite of the fact that in 1997, the average action radius of health structures was 9.69 km, rural and peri-urban zones remain covered insufficiently in terms of infrastructure. This limits the geographical access of populations. Many health structures remain incomplete, whereas often infrastructures are degraded due to lack of maintenance. One of the reasons of the unequal distribution of health structures is a lack of compliance to national health coverage norms.

Furthermore, the weakness of community participation limits improvement of the provision of care.

In terms of finances, the cost of provision of care and drugs, even generic ones, is generally high compared to the purchase power of the majority of the population, especially ever since the CFA franc was devaluated.

This situation is partly due to irrational prescribing and to the fact that the system supposed to assist indigents does not function. In addition, there are no solidarity mechanisms for distributing health costs.

2.1.4. Quality of health services is weak

Many health-care services are not available at health facility level because of lack of staff and competence. In fact, not all existing health facilities offer the complete minimum health package, as some health districts are not operational.

Health facilities suffer from a poor reception of clients; bad client perspective of the services; poor organisation of services resulting in long waiting times amongst others. Health referral structures are not always accessible: they cannot take charge of certain diseases due to inadequate equipment and lack of specialised personnel. Referral and counter-referral are poorly organised.

The quality of health-care services provided is insufficient. Services do not always comply with established quality criteria, such as continuous availability, integration, continuity, globality and client satisfaction. The absence of a national quality assurance programme contributes to the decrease in quality of health services and consequently to the decrease in use by the population over the past 10 years.

2.1.5. Management of human resources in the health sector is inefficient

The management of human resources in the health sector is not yet operational. There is no formal policy for developing human resources, which in part explains their quantitative and qualitative inadequacy. Basic training and on-the-job training of health staff is inadequate.

Management of human resources is characterised by the lack of control over resources, faulty job descriptions wrong ditribution of ersources in respect to needs,and insufficient staff motivation.

2.1.6. The institutional framework is weak

The weak institutional framework entails an insufficient definition of hierarchical and operational relations between the different health system levels. This results in inadequate intra-sectoral coordination, a lack of coordination capacity in the health sector whole an inadequate legal framework combined with lack of implementation of existing laws. Assistance provided by the central level in terms of management, planning, monitoring and evaluation is insufficient. Finally, lack of compatibility between administrative decentralisation and health system decentralisation undermines organisational system gains.

2.1.7. Intersectoral coordination and collaboration are insufficient

Coordination of interventions implemented by partner agencies (private sector, donor agencies, NGOs) is insufficient. Existing coordination bodies do not function in satisfactory ways. Consequently, the resources of the Ministry of Health are poorly known, poorly used and partner contributions are undermined.

Furthermore, many health determinants do not fall under the direct area of competence of the Ministry of Health (for ex. provision of drinking water, sanitation, nutrition, security of the roads). Also, inter-sectoral collaboration has not been set up at all health system levels and activities which should contribute to better health remain compartmentalised at central or peripheral levels.

For the sake of our presentation, we have identified the following problems for further examination in this paper:

- weak service utilisation;
- inadequate service quality.

The importance of these two problems and their interrelations have been underlined by several evaluation and statistics reports, health studies and official speeches by national authorities.

2.2. Orientations in policies of quality promotion

In the health sector there is growing demand amongst service users for quality services, and a growing requirement amongst service providers contracted by public structures and communities to guarantee appropriate care. In spite of the magnitude of the problem as demonstrated by numerous experiences, quality remains poor. Burkina Faso has therefore commenced a process of implementation of quality measures and policies in health services. This process started in January 2000 with a national workshop to support the health care quality assurance programme. Normative approaches led to a search for consensus on the definition of quality. It became obvious that quality may be defined in many ways due to different perceptions of it by different actors such as patients, service providers, administrators etc. We will however consider quality as comprising several elements including staff competence, access, effectiveness, efficiency, user satisfaction, globality, continuity and unharmfulness. In the PSN and PNDS documents, the Health Minister defined priority health interventions as follows:

- implementation of a national strategy of quality assurance;
- improvement of availability of and access to quality essential drugs;
- improvement of performance of health programmes, including supporting activities;
- improvement of financial access by the population to health services.

3. IDENTIFICATION OF SOLUTIONS: EXPERIENCES FROM BURKINA FASO

3.1. Studies conducted on the issue

3.1.1. "Evaluation of the links between structural macro economic adjustment programmes, health sector reforms, and access, utilisation and quality of health services"

This research initiative involves several countries including Burkina, where the study was conducted by a multidisciplinary team. The study covers the period 1980 to 1999.

Certain measures were taken regarding the organisation of public, private and traditional health systems, in order to address the deterioration of the health status in the country. As was the case in other countries, these reforms were part of the structural adjustment policies adopted by Burkina Faso in 1991. Predetermined reforms :

· decentralisation of the health system;
· promotion of cost recovery in health services;
· rationalisation of drug supply and distribution;
· introduction of hospital reform;
· promotion of private practice;
· promotion of cooperation with traditional medicine.

3.1.2. Conceptual framework of the study

Diagnostic workshop with service providers for determining quality of services, Senegal. Source: JHU/CCP, Photoshare.

Health expenditure is possibly the first lever through which adjustment can exercise its influence on the health service system. Orientations and the general organisation of the health system may be completely remodelled through institutional reform and measures aimed at promoting the private sector. These measures will consequently affect the different aspects of health services: their availability, quality, pricing, and geographic and financial access of the services provided, financial autonomy of the facilities, etc.

Modifications related to pricing, quality and availability of health-care services offered will affect the perceptions of the population regarding health service quality and costs.

The combination of transformations affecting on the one hand quality, availability and pricing of services, and on the other hand health needs, capacity to pay and household preferences for care, may result in enormous changes in the access and utilisation of health services. The most vulnerable population groups, such as poor people, women, children, may thus be particularly exposed to the risk of exclusion.
The study distinguishes in this respect:
a) three levels of impact;
b) three types of impact (see figure below):

– impact on the determinants of supply of health services, i.e. on the health service    systems (regulation, organisation and funding) and attributes (availability, price, and    quality);

– impact on the determinants of demand for health services at community level (work,    resources, consumption, exposure to risk, nutrition, education) and at household    level (health needs, ability and willingness to pay, perceptions on costs and quality    of care, perceived access);

– impact on use of health services, which will vary according to changes in   supply    and demand

3.1.3. Objectives

To evaluate the links between structural adjustment programmes, sector reforms, and service use and quality.

For the analysis of the above described situation, the research team developed a number of study hypotheses, including:

1) The increase of human and financial resources of the health sector is not accompanied by a behaviour change by public sector health providers in terms of welcome and organisation of services.

2) Through deregulation (e.g. facilitating the establishment of services and their operation), structural adjustment programmes will increase the service supply and quality, and lessen private sector price increases.

3) Increases in costs and prices of care have generated new types of behaviours, both amongst service providers (supply of home-based care, private health care practice) and with the population (clients) (preference for quality care which is less costly, organisations).

4) Structural adjustment programmes have strengthened availability, perception (of quality) and access to services at peripheral health facility level and at hospital level.

3.1.5. Study results

In this paragraph we will present study results concerning the quality and utilisation of services.

Health service quality

A large majority of users is satisfied with the care received in the health structures visited. Satisfaction levels vary according to the area. In the Bazega area satisfaction is the highest (approx. 91%). Thus, we can conclude that the increase in resources in health centres in urban zones did not result in a perceived increase in quality by the service users. Services provided by public structures receive larger appreciation than services provided by private or traditional structures. Within the public sector, services provided at health centre level receive larger appreciation than those provided at hospital level. It seems surprising that services provided in the urban zones, which benefit from more resources in terms of staff and technical equipment, are less appreciated than services provided in rural areas. The nature of relations between health staff in rural zones, different from urban zones, may explain this better image of rural services, as their provider has more opportunities to be close to their patients. Determinants for client satisfaction include "prescription of good products", "adequate diagnosis" and "effectiveness of the prescription" in terms of contributing to solving the health problem. Other determinants such as friendliness of the providers, time contributed to listening and examining the patient seem to contribute less to a positive appreciation of service quality by the health centre users.

Health service use

The analysis of previous studies and health statistical data shows a drop in health service attendance and coverage.

Under-usage has also been identified for preventive services, such as vaccination, general consultations, family planning, etc.

Regarding illness and disease, patient behaviour varies from one region to the other and from one patient to the other. Several studies (Solenzo 1985, Nouna 1993 et EDS 1993) indicate low attendance rates of existing health facilities, especially in the rural areas, where only 10 to 14% of patients attend health centres3 and where the majority of cases is treated outside of the modern health facilities. In Bazéga, Gourma et Séno, 25% of persons interviewed who reported having been ill during the previous 15 days did not undergo any treatment, either within the family or in another treatment location.

Criteria for choosing provider of treatment include habit (22, 8%), facility of access (19,6%), high quality of care provided (16, 6%), and are amongst the second group of choice criteria.

A majority of 84, 2% of users seem satisfied with the results of their hospital visit. Reasons cited for satisfaction were: effectiveness of treatment (53, 3%), and quality of care and drugs (13, 4%).

The absence of above-mentioned elements would constitute reasons for non-satisfaction together with cost of care and quality of welcome.

3.2. "Study of the population's perception of quality of care in a health district in a rural area (February 1998)

3.2.1. Introduction

Woman signing a medical consent form with a doctor, "Delivery of Improved Services for Health (DISH) Project", Uganda. Source: Kakande H., DISH II Project, Photoshare

In view of the continuing decrease of attendance levels of health services, several measures and strategies have been implemented in order to increase facility utilisation. Some studies showed that these measures have only had limited results and that low attendance of health services was attributed to poor quality of care. This is why the PRAPASS team chose to pilot one of the quality assurance approaches in a rural district where they were already working. But since base line data were lacking, a preliminary study was conducted with the following objectives:

- identify criteria used by the district population to assess the quality of modern health   services;
- obtain basic data on the population's satisfaction with the health services delivered   by their referral health facilities.
The study was conducted during two weeks in 1997, using 20 focus groups consisting of 6 to 12 members each. A report was drafted of which we will present a number of results.


3.2.2. Results

Criteria for quality

Criteria for quality mentioned by the interviewees include:

- leaving the health facility cured (treatment capacity);

- competence of the staff involved in the treatment. A good health facility should have   "good persons" at its disposal, staff members who like their work, have adequate   capacity ("sufficient things in their head, everything in their head" as historian KiZerbo   from Burkina Faso said). This would influence patient's attendance of health centres   and staff's behaviour and attitude during the consultation (gestures, no hesitation,   etc.).
- interpersonal relations (know how to put the patient at ease, understand the patient,   do not discriminate, welcome them and smile!);
- availability of staff: disease does not give warning before its arrival nor does it   respect opening hours ;
- affordability: getting well without spending a lot of money; drugs not too expensive;
- geographic access: health facility located in the vicinity;
- cleanliness of services, disposing of sufficient equipment, staff and drugs.

According to the interviewees, the most important criteria for quality are:

- sufficient personnel;
- competent and accessible staff members;
- pleasant welcome offered;
- availability of drugs;
- completeness of equipment and supplies;
- basic care guaranteed.

User satisfaction :

The study showed that almost all persons interviewed had attended a health facility for different reasons. Using the above-mentioned quality criteria, each interviewee gave his/her evaluation of the services provided by the health facility. The study results showed that some communities who had even up to four health facilities in their area, cited lack of quality of care. These results will be useful for working towards improving quality of care.

Notes

Since several years, Burkina Faso is piloting the implementation of activities aiming at improving service quality. We would like to discuss two pilot projects :

Le Cercle d’Or (Golden circle)

This is a service quality initiative impacting on both the supply and demand for family planning services. The initiative aims at increasing the use of modern family planning methods while maintaining a high level of service in order to please the clients. The programme is implemented through the regional Family Planning and AIDS Prevention project (Santé Familiale et Prévention du Sida: SFPS) and comprised two essential activities: accreditation and monitoring; and promotion of the Cercles d'Or (CO).

In Burkina Faso, this initiative proposed by the SFPS project is being implemented in close cooperation with the Ministry of Health.
The SFPS project is operating in four countries in West and Central Africa: Burkina Faso, Cameroon, Ivory Coast and Togo.

Cercle d'Or sites

In 1993, the CO started with a Mother and Child Care service (MCH). Today within the SFPS zone there are 45 recognised CO sites.

Site evaluation mechanisms

The teams composed of medical doctors and midwifes (2 for each site) are in charge of evaluating the competing sites. The team members are trained on the subject and use pre-defined evaluation criteria.

The evaluation criteria include the following topics:

- access et availability;
- interaction between clients and providers;
- medical barriers;
- prevention of infection;
- training and competence of providers;
- stock management and reporting.

Each topic is divided into 3 sub-topics. Each year, all the sites participate in a competition to win the health facility quality prize, including those who already received prizes previously. For some this will result in a continuous battle to keep their title whereas others want to win their first titles!

The value of the prize

The health facilities who win the Cercle d'Or prize can benefit from different types of assistance: financial, material and technical. A certain level of "moral" motivation is required by the CO promoters as well. Highly mediatised ceremonies, attended by local and national authorities, are organised in Burkina at the launching of the competition and at the prize award ceremony. There is even a patronage system by organisations and individuals.

The CO experience has enabled going beyond theory and putting the notion of quality into practice. More and more, different socio-economic development actors are participating in the initiative and each Prize obtained is a source of pride for an entire region!

Quality circles

Composition

Quality circles are a pilot activity set up by the ABCERQ (Burkina association of groups for quality and participative management), an association of circle groups created in 1992 and which was publicly recognised in 1995. The quality circle is composed of workers of the same unit, who on a voluntary basis decide to form small groups to discuss problems related to their work. The ABCERQ association includes three types of members, of which the majority is composed of local industrial enterprises. Health services do not seem to be included in this pilot project. An attempt involving the National Hospital in Ouaga failed.

Objective

The quality circles aim at attaining several types of objectives, which are of operative and relational order and which concern integration and adhesion.

Start-up procedures

The start-up procedure includes four phases.

The orientation phase is geared towards the direction office of the company, which should decide to reorient its management style following the circle results.

The structural and material organisation phase includes the setting up of a decision body for the quality circles hierarchy. This is a sort of committee which officialises the company's commitment to create quality circles, defines the company's policies towards the quality circles and sets up the training process (facilitators, animators...).

Following the training period, which represents the most important phase, the company can set up its first quality circles.